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Data Elements

Data elements sent to NC DETECT from emergency departments, the Carolinas Poison Center data and the Pre-hospital Medical Information System data are detailed in three separate tables below.

Emergency Department Data
Data elements listed below are collected by NCHESS, although Triage Note is currently an optional element and hospitals are not required to send it.
Inclusion Criteria for NCHESS Case Reporting: Patients treated in the participant ED regardless of their disposition and patients Triaged who then leave AMA or without being seen. Also patients treated in the ED and then admitted to the hospital should be included.
Exclusion Criteria for NCHESS Case Reporting: Patients triaged away to a clinic or directly admitted to an inpatient unit.

Emergency Department Data Elements Typically Available in NC DETECT Line Listing Reports

Name

Description/Notes

Internal Tracking ID

NC DETECT-generated identifier that uniquely identifies a patient at that healthcare facility/system. Can be used to track repeat visits by the same patient to the same facility/system

Patient Age

Available in years

Sex

M (Male), F (Female), U (Unknown)

Patient City

Patient’s city of residence

Patient County

Patient’s county of residence

Patient ZIP

Patient’s ZIP of residence (5-digit)

Patient State

Patient’s state of residence

Visit ID

NC DETECT-generated identifier that uniquely identifies that ED visit

Hospital

Emergency department facility where patient sought care

Insurance Coverage (or Other Expected Source of Payment)

Entity or person expected to be responsible for patient's bill for this ED visit (private insurance, self-pay, Medicare, Medicaid, etc.)

Arrival Date and Time

First date and time documented in patient's record for this ED visit

Transport Mode

Patient's mode of transport to ED (walk-in, ground ambulance, etc.)

Chief Complaint

Patient's reason for seeking care or attention, expressed in terms as close as possible to those used by patient or responsible informant

Triage Notes

Supporting information for Chief Complaint

Blood Pressure

Blood pressure taken at triage (when available)

Initial Temperature

Temperature taken at triage (in Celsius)

Injury Code(s)

Encoded description of injury event that precipitated patient's ED visit; ICD-9-CM E code(s)

Disposition

Patient's anticipated location or status following ED visit (discharged, admitted, transferred, died, etc.)

Disposition Diagnosis Description

Practitioner's description of condition or problem for which services were provided during patient's ED visit, recorded at time of disposition

Diagnosis Code(s)

Up to 11 ICD-9-CM Final Diagnosis Codes

 

Carolinas Poison Center (CPC) Data Elements

The Carolinas Poison Center (CPC) is the designated Statewide Poison Control Center for North Carolina and certified as a Regional Poison Control Center by the American Association of Poison Control Centers.  CPC is an emergency telephone resource of poisoning information, staffed 24 hours a day, seven days a week, by registered nurses and pharmacists (specialists in poison information) who are specially trained to provide diagnostic and treatment advice for acute and chronic poisonings to the public and healthcare professionals.
CPC receives over 120,000 calls per year.  More information is available at http://www.ncpoisoncenter.org/.

CPC Data Elements Sent to NC DETECT

Data Element

Description

Call Date and Time

Date and time of call to CPC

Call Type

Call type listed as exposure,  information or drug identification

Call Type Category

Subcategories for information call types

Caller City

City where call was made

Caller County

County where call was made

Caller Location Code

Zip code or area code/exchange of caller

Caller Site

Location of caller at initial call (residence, workplace, etc.)

Caller State

State where initial call was made

Caller Zip

Zip code where call was made

Case Number

Unique number for patient

Chronicity

Records exposure as acute or chronic

Clinical Effects

9 categories of clinical effects (cardiovascular, dermal, gastrointestinal, hematologic/hepatic, neurological, ocular, renal/genitourinary, respiratory, and miscellaneous). Each clinical effect is recorded as no effect, related, not related, or unknown if related

Duration of Effect

Duration of clinical effects

Exposure Duration

Duration of chronic exposures

Exposure Reason

Type of exposure if call type was an exposure call

Exposure Site

Location of the patient when the exposure occurred

Final Health Care Facility

Type of health care facility for patients transferred from the initial HCF to a second HCF

Follow up Number

Number of follow-up contacts for each patient

Initial Health Care Facility

Type of health care facility patient is in or referred to

Medical Outcome

Final outcome of patient after final follow-up

Multiple Patients?

Yes/No

Patient Age

 

Patient Age Group

 

Patient Gender

Patient Pregnancy Duration

Number of weeks pregnant

Product ID

Identifier for product involved in call

Related Case Number

Case number of primary case/call related to patient

Route

Exposure Route: Aspiration, Bite, Dermal, Ingestion, Inhalation, Ocular, Other, Otic, Parenteral, Rectal, Unknown, Vaginal

Scenarios

7 categories of possible exposure scenarios (dosing/therapeutic error, vapor/fume problems, child-resistant closure on product, access to product, confusion about product, pesticide problems, miscellaneous). Up to four scenarios can be selected per case

Substances

Information on all substances involved in exposure

Therapies

2 categories of therapy provided (decontamination or other). Each therapy is recorded as not recommended, recommended, performed, recommended and performed, or recommended, known not performed.

 

Pre-hospital Medical Information System (PreMIS) Data Elements

The Prehospital Medical Information System (PreMIS) is an internet based EMS information system. The PreMIS system provides a data entry and reporting capability for the evaluation of EMS patient care and system performance. The system is in use by over 800 EMS agencies, 40,000 technicians, and maintains over 1,000,000 records per year. More information is available at http://www.emspic.org.

PreMIS Data Elements available in NC DETECT reports

Data Element

Description / Notes

Agency county

EMS Agency county

Agency name

EMS Agency name

Anatomic location

Pick list: Abdomen, Back, Chest, Extremity-Lower, Extremity-Upper, General/Global, Genitalia, Head, Neck

Chief complaint

Free-text narrative of the patient's chief complaint, as close as possible

Destination Name

 

Destination Type

 

Dispatch complaint

Abdominal Pain, Allergic Reaction, Animal Bites, Assault, Back Pain, Breathing Problems, Burns, Carbon Monoxide/Inhalation, Cardiac/Respiratory Arrest, Chest Pain, Choking, Convulsions/Seizure, Diabetic Problem, DOA, Drowning, Electrocution, Eye Problem, FALLS/Back Injury, FIRE, HAZARDOUS MATERIAL, Headache, Heart Problems, Heat/Cold Exposure, Hemorrhage/Laceration, Industrial/Machinery Accidents, Ingestion/Poisoning, LIFE LINE, OVERDOSE/POISONING, Pregnancy/Childbirth, PSYCHIATRIC/SUICIDE, SEIZURES, Sick Person, Stab/Gunshot Wound, STANDBY/SPECIAL EVENT, STROKE, SUBSTANCE ABUSE, Traffic Accident, TRANSPORT, Traumatic Injuries, Unconscious, Unknown Problem/Man Down, Transfer/Interfacility/Palliative Care, MCI

Incident address

 

Incident city

 

Incident Disposition

Treated, Refused, Dead. EMS calls with an incident disposition of Cancelled, No Treatment Required, or No Patient Found are not sent to NC DETECT.

Incident Facility Code

 

Incident Location Type

 

Incident state

 

Incident zip code

 

Mass casualty

Yes/No

Patient address city

 

Patient address state

 

Patient address zip code

 

Patient age

 

Patient age unit (Years, Months, Days, Hours)

 

Patient birth date

 

Patient Destination date and time

 

Patient gender

 

Patients at scene

single or multiple

Primary symptom name

Pick list: Bleeding, Breathing Problems, Change in Responsiveness, Choking, Death, Device/Equipment Problem, Diarrhea, Drainage/Discharge, Fever, HEADACHE, Malaise, Mass/Lesion, Mental/Psych, MENTAL STATUS CHANGE, Nausea/Vomiting, NONE DETECTED, Pain, Palpitations, Rash/Itching, Swelling, Transport Only, Weakness, Wound

Provder Primary Impression

 

Provider Secondary Impression

 

Secondary complaint

Free-text narrative of the patient's secondary complaint(s), as close as possible a quote from the patient

Secondary symptom name

See Primary Symptom Name

Unit notified timestamp

 

Vital Signs: Blood pressure, Temperature, pulse oximetry, respiratory rate

 

Work related

Yes / No / Not Recorded

Revised 11/9/2011